3201 Acute Portal Vein Thrombosis Presenting With Atypical Abdominal Pain: A Rare Presentation

Abstract

INTRODUCTION: Portal vein thrombosis (PVT) is an uncommon etiology of transient abdominal pain that left undiagnosed can present with severe complications including variceal hemorrhage, intestinal ischemia, and portal biliopathy. The clinical presentation of PVT is highly variable and depends on the speed of development and extent of occlusion. Rarely do partial acute PVTs present with symptoms. As a result, many PVTs are found incidentally on CT scanning performed for other indications. Management of acute PVT relies on anticoagulation over a three- to six-month period, however this practice has not been evaluated in randomized trials. Current practices rely on the principal that spontaneous recanalization of PVT is rare compared to rates of recanalization as high as 40% in anticoagulated patients. We present a rare case of partial PVT presenting with localized abdominal pain and fever. CASE DESCRIPTION/METHODS: A 63-year-old male was admitted from the Emergency Department with right upper quadrant pain and subjective fever. Past histories remarkable for hypertension and alcohol use disorder. Patients examination revealed a soft abdomen with severe right upper quadrant tenderness. On initial presentation the patient had a fever of 100.5 degrees Fahrenheit sustained for 1 hour that self-resolved within 4 hours of admission. CT scan of the abdomen and pelvis revealed linear hypodensities in portal vein branches to the right anterior hepatic lobe and lateral segment of the left hepatic lobe and was otherwise unremarkable. Follow-up duplex ultrasound of the hepatic portal veins corroborated the CT findings. Anticoagulation was started initially with heparin and then subsequently transitioned to rivaroxaban with plans to continue anticoagulation for six months. Patient had complete resolution of abdominal pain within 24 hours of initial presentation. The patient was evaluated for underlying prothrombotic disorders and investigations revealed positive lupus anticoagulant. Patient currently awaits repeat imaging to document resolution of the PVT. DISCUSSION: PVT can present a diagnostic challenge as presentation, though typically asymptomatic, can also be highly variable. Review of the literature demonstrates atypical presentations including nonspecific dyspepsia, epigastric pain mimicking pancreatitis, and colicky abdominal pain and diarrhea. Recognition and early treatment of PVT is important to prevent portal hypertension and its associated long-term complications.